Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit
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LUTFI AL-JAZZAZI 47 YEARS BULGE L4-5 DISC WITH LEFT EXTRUDED FAR-LATERAL DISC L5-S1.
The patient came to the clinic 24-June-2012
complaining of numbness big toe left foot for
one month with left sciatica.
spine performed 20-June-2012 showing left
far-lateral extrusion L4-5 disc.
examination, the patient now is not limping with
exaggerated scoliotic stance. SLRS was 80
degrees in the left
with pain. There is weak dorsiflexion left foot
3/5 and hypalgesia left L5 territory.
patient was advised to keep in conservative
treatment, but his sciatica increases for what
MRI lumbar spine repeated 08-July-2012
confirming the persistence of the extrusion.
Left L5 foraminotomy with
reflection of the L4-5 ligamentum flavum to the
right. The left L5 root was inspected and
exploration of the far-left area revealed minor
changes. Discectomy of L4-5 from the left.
Further exploration with identification of the
left L4 root was done with no big convincing
piece. Considering that the patient has
lumbarization of the sacrum, inspection the left
far-lateral area of the L5-S1 revealed a big
piece extruding from the annulus fibrosis, which
was removed in one big piece. All stages of
surgery were done under the image-guided
control. The ligamentum flavum was preserved at
both levels. Guardix-sol was applied to decrease
the postoperative adhesions.
Routine closure of the wound. Smooth
postoperative recovery. The power of right foot became
Do not ever trust the radiologic reports. You
must use only your eyes in interpretation the
morphological picture of the the patient. In
case of conflicts redo another MRI to avoid such
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The patient still has
an estimated postoperative recurrence about 7%,
because the disc space is still not shallow.
The patient did MRI twice and the radiologists
in both investigations did not notice the
far-lateral extrusion in their report, even they
did not included the sagittal study to cover the
far-lateral aspect of the vertebral body. The
last one even did not included the reference
thumbnail to confirm the level of the
far-lateral extrusion. In the last MRI the L4-5
was severely involved and the L5-S1 was more or
less more normal. This conflict of data and bad
interpretation of the radiologists led to this
The guising of surgeon about the dimensions of
the extrusion could only resolve the problem, so
as not to miss the real huge compression.
Notice: Not all operative activities
can be recorded due to lack of time.
Notice: Head injuries and very urgent surgeries are also
escaped from the plan .